LIZ HULL investigates the merry-go-round of mediocrity and cover-up which allowed NHS fats cats to evade accountability for Lucy Letby’s evil crimes
Each barely bigger than a shoebox, the 29 black coffins – every one decorated with a white cross – marked a devastating moment in NHS history.
It was back in 1998, and these tiny coffins – laid by grieving families outside a hushed General Medical Council hearing – symbolised the 29 babies who had died after heart surgery at Bristol Royal Infirmary.
Devastatingly, that wasn’t even the full number. When a public inquiry into the scandal concluded three years later, it found that as many as 35 children had perished needlessly in the early 1990s due to a string of hospital failings.
The inquiry blamed in large part the ‘poisoned atmosphere’ between management and doctors – and tried to address this by calling for a formal regulation system for all NHS managers. But the regulations were never introduced.
Similar concerns were raised by campaigners after the Mid Staffs scandal, which saw as many as 1,200 patients die from poor care between 2005 and 2009 at Stafford hospital.
And again after the Morecambe Bay Investigation in 2015, following the deaths of three mothers and 16 babies at Furness General Hospital in Cumbria. Yet, nothing happened.
Tragically, it has taken another decade and the deaths of several more children for the issue to finally make it to the top of the Government’s in-tray.
Why is it being taken seriously at last? Because of Lucy Letby – the nurse who killed seven babies while working at the Countess of Chester Hospital between 2015 and 2016.
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Lucy Letby at the Countess of Chester hospital where she killed seven babies
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Ian Harvey, medical director at the Countess of Chester Hospital
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Tony Chambers, the Countess of Chester’s £160,000-a-year former chief executive, meets the then-Duchess of Cornwall in 2014
Earlier this month, oral evidence given to the public inquiry into her crimes drew to a close. One of the key questions now being considered by our mandarins and legislature is ‘how can accountability of senior managers in the NHS be strengthened?’ It truly has reached the stage of how rather than if.
For the inquiry overseen by Lady Justice Thirlwall has laid bare a merry-go-round of mediocrity in the highest echelons of the health service, one in which failing managers have been allowed quietly to resign from their posts, only to pop up at hospitals elsewhere.
The inquiry heard this culture is so ingrained that there are bureaucrats at NHS England (formerly NHS Improvement) dedicated to providing a ‘safety net’ for managers so they can be recycled into other jobs without any detriment to their careers or swollen salaries.
So close-knit is this revolving-door policy between hospitals that former parliamentary and health ombudsman Sir Rob Behrens compared it to the way senior staff trade jobs among the ‘magic circle’ of top law firms. He called for a new regulatory body with the power to ban NHS executives, who are often on six-figure salaries, from taking up senior posts if they are found guilty of serious misconduct.
Of course, this cannot explain all the failings at the Countess of Chester Hospital that allowed Lucy Letby to continue killing. But it was undoubtedly part of an NHS culture that led to a breathtaking arrogance and lack of concern among the hospital’s managers.
I was appalled by much of what I learnt about this culture from the inquiry. And I write as someone who sat through every day of Lucy Letby’s ten-month trial and wrote and co-presented the Mail’s ground-breaking podcast series on her.
Take Tony Chambers, the hospital’s £160,000-a-year former chief executive when Letby embarked on her 13-month murder spree. With breathtaking flippancy, he told the inquiry in November how the NHS helps chief executives move between trusts ‘all the time’ when they’re in trouble. He said the process had a nickname: ‘Going into the donkey sanctuary.’ The ‘donkey sanctuary’ was where Mr Chambers was heading in September 2018 following Letby’s first arrest.
Lyn Simpson, then-executive regional managing director for the North at NHS Improvement (now NHS England), told the inquiry she had contacted him to ‘negotiate’ his removal. She claimed it was her job to persuade Mr Chambers to change roles after the hospital’s seven paediatricians told the Chester board they would no longer work for him.
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Evil neo-natal nurse Lucy Letby (pictured in mugshot) was sentenced to life imprisonment in 2023
They said they had been bullied and victimised for blowing the whistle on Letby – and would be holding a secret vote of no confidence to get Mr Chambers out.
For his part, Mr Chambers told the inquiry he didn’t know about the vote, although he admitted he had agreed to ‘step aside’ on condition that, wherever he ended up, he would remain as a chief executive at no ‘cost’ to his NHS career. Without irony, he insisted he’d done nothing wrong in terms of his contract – even though, by this stage, Letby had already killed seven babies and attempted to murder seven more.
Referring to being told that he should step down, he told the inquiry: ‘I remember specifically a conversation: ‘What do you want from this, Tony?’ It felt like it was almost a bit of a negotiation really, you know, in that you are putting the best interests of the organisation first.
‘I said: ‘I would rather that [it] was not at the expense of my career.’ I had a contract as a chief executive. I had done nothing that was in breach of that contract, so therefore I had a contractual right, as a minimum, to serve six months’ notice.
‘It was me, I believe, again putting the best interests of the patients first, at the expense of my own career and family. I wanted to be able to work my notice in [another] organisation, so I then had an opportunity to reset and maybe rebuild.’
Mr Chambers – who has been described by other witnesses who worked at the hospital as ‘intimidating,’ ’emotional’ and ‘aggressive’ – did eventually resign days later.
But he rejected the job offered to him by the northern director for NHS Improvement because it wasn’t an equivalent role. In other words, he felt he could do better elsewhere in the country.
He left the North West and went on to secure several lucrative, short-term roles at hospitals in the South. He even bragged about a £55,000 pay rise by taking on the £215,000-a-year job as the boss of Barking, Havering and Redbridge NHS Trust in east London in January 2020 – while Letby was still being investigated.
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A court artist sketch of Letby at Manchester Crown Court as she went on trial for murdering babies
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Letby worked at the Countess of Chester Hospital when she carried out her evil crimes
At least his right-hand man, medical director Ian Harvey, had the grace to retire to his farmhouse in the south of France and stop working in the NHS altogether.
Insiders told the Mail the orthopaedic surgeon, who retired with a £1.8 million pension pot, joked with a member of staff that ‘they would have to find me first’ when the prospect of giving evidence at a public inquiry was raised in 2018.
But Mr Harvey wasn’t laughing when, over the course of two days in November, he was grilled on oath about claims he breached the hospital’s statutory ‘duty of candour’ by keeping suspicions about Letby from the parents of babies who died. He was also accused of failing to tell them about the external investigations into baby deaths he’d commissioned instead of immediately calling in police.
He was repeatedly exposed for not telling the truth and withholding information from the families of the babies, the coroner, the paediatricians and the hospital board.
The GP mother of one baby boy murdered by Letby even accused Mr Harvey of lying to her face. She told the inquiry: ‘That someone could sit with you and tell you something untrue about the death of your child is something that I cannot believe happened even now.’
When a hospital’s statutory duty of candour is breached by a member of staff, it is the hospital rather than the individual that receives a punishment from the Care Quality Commission watchdog, be it a fine or de-registration.
But a proposed new law is designed to ensure the individual is punished. Known as the Hillsborough Law, it was first suggested in March 2017 after the new inquests into the 1989 Hillsborough disaster – when 97 football fans were unlawfully killed in a crush and wrongly blamed by police to cover their own failings.
Backed by lawyers and relatives of victims, Prime Minister Keir Starmer announced in September that he was committed to introducing the law to Parliament before the 36th anniversary of the disaster in April. It will make it a crime for senior NHS staff and other public servants to lie and mislead public inquiries. Campaigners say that making individuals accountable would go some way to eradicating a ‘cover-up’ culture at hospital boards.
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The entrance to the Women and Children’s building at the Countess of Chester hospital
As Sir Rob Behrens suggested, some senior bodies ‘are more interested in protecting the reputation of their organisation rather than dealing with patient safety issues’.
Mr Chambers and Mr Harvey denied on oath that they prioritised the hospital’s reputation over the safety of the babies who died. But the inquiry heard that another hospital board member had hoped to ‘pull the shutters down and contain the situation’ after suspicions about Letby were voiced – raising fears over how widespread such attitudes are.
It will be up to the inquiry’s Lady Justice Thirlwall to decide why both Mr Harvey and Mr Chambers failed to call police immediately when paediatricians demanded Letby be removed from the unit following the deaths of two triplets in June 2016. One reason, perhaps, was a comment by the hospital’s director of corporate and legal affairs, Stephen Cross, who warned of ‘blue and white tape everywhere’ – in other words, police tape – and media trucks in the hospital grounds.
Mr Cross’s appointment was controversial in itself, for the Mail has learned that many years ago, he left his 29-year career with Cheshire Police in disgrace following
disciplinary matters. A spokes confirmed that Mr Cross, who is a senior Freemason in Chester, resigned after being demoted from chief inspector to police constable when he was found guilty of misconduct in 1997. Sources say he was caught ‘drinking on the job’.
Being demoted to the lowest rank rather than being sacked meant Mr Cross likely kept his police pension and was able to resign quietly – helping secure a top job at the Countess of Chester Hospital two decades later, in 2007.
Dr Stephen Brearey, the lead consultant on the Countess’ neonatal unit, told the inquiry that concerns around Mr Cross’s influence sparked rumours of a ‘Freemason connection’ at the trust. It also raised questions over whether it had followed any processes ‘in terms of fit and proper candidates for executive roles’, he added.
The hospital said it wasn’t appropriate to comment, while a spokesman for Mr Cross said he was seriously ill and ‘not in a position to provide any comment’.
Still, given that blunder after egregious blunder was laid bare at the inquiry, it is now surely a matter of when – not if – the statutory regulation of individual NHS executives is introduced.
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Letby murdered the babies in the hospital between 2015 to 2016
The inquiry is due to hear closing statements in March, with Lady Justice Thirlwall expected to deliver her report in the autumn. But the tide appears to be turning already. In November, Health Secretary Wes Streeting announced a three-month consultation on managerial regulation, saying ‘strong and accountable NHS leadership will be critical to fixing a broken NHS’.
The proposals have been hailed by campaigners. James Titcombe, whose nine-day-old son Joshua died at Furness General Hospital in 2008, said: ‘Too often, the same problems occur over and over again in the NHS. It needs to become an organisation of memory, because at present it’s one with collective amnesia.’
In short, now is the time for ministers to sit up and listen. The words of the grieving parents of Letby’s victims ought to be ringing loud in mandarins’ ears.
As one mother, whose premature baby girl died after being harmed by Letby, said: ‘Managers need to be personally accountable. They are dealing with people’s lives and the impact of that is for ever.’